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Tver statistics are similar to Russia as a whole as Table 1 points out, where problems exist related to both (i) total funding for health care and (ii) the efficiency or relative value of the way funds are spent for health care services. Traditionally, the health sector was viewed as a "non-productive" service sector, and funded only with residual funds available after other programs were funded. Chronic underfunding was matched with poor and often perverse incentives in the use of funds for services. For greater detail on Russia generally, see, for example, the ZdravReform Russia Country Action Plan, November 1994.
{PAGE } !,(3!( !( ! !( *! ,,!?(,, !!! **( ( * ,!; ?1,( 55$1 !* < ! !=* ,!( / () !
{PAGE } Table 1
Data on Tver Oblast and the Russia Federation (1991-1994)
1991 1992 1993 1994 Russia (1994)
Category
Demographic Population (thousands) 1669.2 1660.5 1656.2 1647.5 148,200.0 % 0- 18 N/A 26.0 25.8 25.6 N/A % 19-64 N/A 59.2 58.8 58.5 N/A % 65+ N/A 14.8 15.4 15.9 N/A
% Female 54.7 54.7 54.6 54.6 N/A % Rural 28.2 28.1 28.0 28.2 26.9
Infrastructure Physicians (per 1,000 pop) 3.8 3.7 3.7 3.8 3.9 (1993) Ratio GPs/physicians 21.0 22.0 22.0 21.0 15.0 Hospital beds 13.5 13.1 13.0 12.9 12.2 (1993) (per 1,000 pop)
Resource Use Hospital Admissions 21.4 20.0 20.6 21.3 21.0 (as % of pop) Bed Days per Capita 3.7 3.5 3.6 3.7 N/A Occupancy rates 74.7 71.3 75.1 79.4 N/A (as %) Avg. length of stay (days) 17.1 17.7 17.3 17.2 17.0 Contacts (per person per year) N/A N/A 6.4 7.7 8.9
{PAGE } Table 1 Tver Oblast and the Russia Federation (continued)
1991 1992 1993 1994 Russia (1994)
Category
Patterns of Spending Public Spending Per Capita 165 1842 24,502 138,494 N/A Real Per Capita (CPI) 169 244 324 N/A N/A Per Capita ($US PPPS) 127 87 118 N/A N/A
Hospital (%) N/A N/A N/A N/A 69.0 Ambulatory (%) N/A N/A N/A N/A Pharmaceuticals (%) N/A N/A N/A N/A
Outcomes Crude Birth Rate (per 000) 10.1 8.7 7.7 7.7 9.5 Crude Death Rate (per 000) 14.7 16.0 19.4 21.0 15.5 Infant Mortality (per 000) 19.6 18.6 21.5 19.5 19.0 Low Weight Births (% <2500 grams) 5.6 6.0 6.0 7.1 N/A Abortions (per live birth) N/A 1.86 1.87 2.0 N/A Death by Cause (per 000,000) Infectious & Parasitic 10.0 11.7 14.7 17.0 N/A Malignant Neoplasms 233.5 234.2 246.0 239.5 206.6 Circulatory System 914.5 992.9 1192.4 1310.9 837.3 Respiratory System 65.7 64.6 98.9 101.1 N/A Injury and Poisoning 173.6 218.0 293.8 337.5 250.7 Life Expectancy (at birth) Males 61.9 60.2 56.7 N/A 58.2 Females 74.2 73.4 71.0 N/A 71.6 ______Sources: Tver Health Administration, 1995; World Bank, 1995; 1996
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The components of the World Bank Loan program are: 1) Restructuring Cardiovascular Health Services that develops primary and secondary prevention programs focused at the district therapist and family practice level of care. There will also be population-based media and educational programs and activities including (i) health awareness survey, (ii) health promotion materials, (iii) health status inventory, (iv) a new diabetes center, (v) medical equipment for detection of risk factors. Funds also will be used for diagnostic equipment and emergency medicine, such as new and re-equipped ambulances and training emergency response medicine; 2) Family Medicine to facilitate the introduction of family physicians as principal primary caregivers, gradually replacing the "therapist." Building on a strong tradition of teaching family medicine at the Tver Medical Academy, the component would (i) strengthen the teaching capacity at the Academy, (ii) help establish clinics for graduates of the retraining program for family physicians initiated in 1993, and (iii) upgrade six polyclinics and develop a network of Consultation, Diagnostic, and Treatment Centers (CDTCs) to provide outpatient referral support to the new family physicians; 3) Maternal and Child Health and Family Planning will introduce changes in clinical practice standards, building on recommendations of the federal level work groups. It also will create the physical environment to support these changes including an antenatal center, 20 "baby-friendly" hospitals and limited equipment, an interrayon perinatal center, and a family planning and reproductive health center; 4) Restructuring Provider Incentives to provide support for development and implementation of improved provider payment, quality assurance and management information systems. Other activities are a National Training Program in Family Medicine, to design models of family practice for Russia; curriculum and faculty development, including establishment of teaching clinics; and establishing standards for quality improvement and certification and a Monitoring, Evaluation, and Dissemination component, to develop tracking indicators, evaluation activity, training of evaluation methods staff, and workshops and publications related to duplication and replication of best practices.
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{PAGE } Table 2
World Bank/ZdravReform Collaboration in Tver Oblast
CY 1995 CY 1996 1997 - 1998 4
Technical Assistance and Training, Follow-up TA and Training: 1) Technical Assistance and Training ZdravReform Grant Funding Related to Loan Program Related to Oblast-wide Implementation Strategy and Pilot Design: - Working Models Finalized of Pilot Projects
- Quality Assurance - Pilot Projects Implemented 2) Roll-out and Dissemination
- Management and Information Systems
- Payment and Financial Management
1) Bank Loan Proposals Finalized 1) Bank Loan/Funds Flow Begins: Contingency Loan Fund Available for World Bank Oblast-wide Implementation of Pilot Health Reform Project 2) Bank Review and Approval Process 2) Capital, Equipment, Supplies, Projects Personnel
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{PAGE }
Facility Bed SizePhysicians Medical Staff Payment Reform Approach Issues/Comments
Oblast
Children's Hospital 375 109 517 Case-Mix Adjusted Per Case Cadre of in-house experts
Municipal (Tver City)
Hospital/Polyclinic No.1 500 234 844 Per Capita or Fundhold/ Located in Zavolski District (OSMC) GP Fundholding tie-in (pop. 130,000)
Hospital/Polyclinic No.6 585 384 1122 Per Capita or Fundhold/ GP Fundholding tie-in
Rayon
Kuvshinova Central 195 34 248 Per Capita or Rayon At-Risk Agreement to include entire Hospital/Polyclinic GP Fundholding tie-in rayon/tie to CDTC
Nelidovo Central 550 101 706 Per Capita or Fundhold/ Largest central rayon facility in Hospital/Polyclinic GP Fundholding tie-in pilot
Kalyazin Central 240 45 339 Per Capita or Fundhold/ Hospital/Polyclinic GP Fundholding tie-in
{PAGE }
Facility or Geographic Area
Five Pilot Sites: Oblast Children’s Hospital Hospital and Polyclinic No. 1 ("OSMC"), Tver City Hospital and Polyclinic No. 6, Tver City Central Rayon Hospital and Polyclinic/Vishny Volochok Rayon Central Rayon Hospital and Polyclinic/Kuvshinova Rayon
Team Leaders
Dr. Alexander Zlobin (Provider Payment), Dr. Boris Mogilevsky (Quality) Dr. Alexander Molokaev (Management and Information Systems)
Demonstration Site Overview of Approaches
• Payment Methods
Inpatient Case-Mix Payment Refinements (Children’s' Hospital; Hospital No.1) Polyclinic Fundholding (Polyclinic No.1) Capitation Arrangement, with flexibility for experimenting with inpatient and outpatient methods of payment, including incentive-based systems for personnel (Vishny Volochok Rayon; Kuvshinova Rayon; possibly designed for Hospital/Polyclinic No.1, to be determined by January 1996)
note: Hospital/Polyclinic No.6 payment approach to be determined by December 1995
• Management and Information Systems
Standard Data Elements—Clinical, Financial, Administrative Hardware/Software Systems Design Utilization Management Cost Accounting Systems Management Issues, e.g., - Contracts for Facility Autonomy - Contracts for Staffing - Board of Directors - Training of Staff Financial Modeling/Actuarial Data Base Development Financial Management
{PAGE } • Quality Improvement
Continuous Quality Improvement (CQI) Methods and Approaches CQI process Developed in Pilot Sites Complementary Measures and Systems Related to New Payment System, e.g., - Ambulatory Care Measures - Hospital Admission Criteria - Referral Criteria - Discharge/Follow-Up Care Model Clinical Care Pathways
{PAGE }
Suggested Implementation Timeline
October-December 1995
Design and Specify Approaches in Pilot Sites Develop Model Contractual Responsibilities Data Base Development Develop and Award Grant Application for Pilot Sites Begin to Establish Analytic Tools
Suggested Month-by-Month Activities
1) October
Evaluation of current payment approaches at pilot sites Begin to examine specific payment design features of alternative payment approaches - capitation/fundholding - case-mix adjustments for hospital care - how physicians paid - use of withholds - phase-in approach (e.g., fully at-risk in Year 1?) Develop grant application for pilot sites Assemble data for years 1990-1995
2) November
Begin hardware and software design Develop uniform data set Quality workshop Develop model contracts for payer, facilities, and staff Initiate capacity building at pilot sites
3) December
Begin to develop quality indicators, inpatient and outpatient Develop analytic tools, for example - financial/demand modeling - cost accounting methods
{PAGE } January- March 1996
Continue Development of Analytic and Design Tools Finalize Payment Design of Pilot Sites Integrate Analytic Tools with Pilot Site Capacity to Implement Models
Suggested Month-by-Month Activities
1) January
Analytic Tools, for example, - utilization management - refining case-mix measures Finalize Payment Design in Pilot Sites Quarterly Reporting of Results -- Tver and Kaluga
2) February
Analytic Tools, for example, - standards for levels of care (e.g., day-care settings) Develop Preliminary Capitation Rate - risk adjust - high risk pools - disseminate for review and comment
3) March
Final Payment Designs and Adjustments Develop Simulation Data Base Finalize Model Contracts
April-June 1996
Implement Pilot Projects Simulate Flow of Funds through Contracts Integrate MIS and Quality Tools with Payment Changes
1) April
Begin Simulation of New Payment Approach Integrate New Quality Measures and Processes Integrate Management and Information Systems Components Quarterly Reporting of Results -- Tver and Kaluga
{PAGE } 2) May
New quality of care tools, e.g., - Clinical care mapping Continue simulation of new approaches
3) June
New quality of care tools, e.g., - Clinical care mapping Continue simulation of new approaches
July-September 1995
Evaluation of Pilot Payment Models Decisions to Refine Payment Models Full Implementation of New Payment Models
1) July
Begin evaluation of simulation results Evaluation of payment models - financial - information/management - quality - access Quarterly reporting of results: Tver and Kaluga
2) August
Finalize evaluation Decisions to refine payment models
3) September
Full implementation - payment systems - management/information - quality components
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